The initiating event was the hiring of a point of care ultrasound fellowship-trained faculty member with specific expertise in UGNB procedures in September of 2021. This was the first step in establishing a dedicated team for UGNB [PRISM-ISI]. Over the following year, this faculty member—henceforth, the nerve block champion (NBC)—was the primary driver of all intra- and inter-departmental collaboration as well as coordinating the materials and electronic health record (EHR) changes required for administering UGNBs. A critical factor in the NBC’s success was consistent clinical leadership support [PRISM-OC] for the UGNB program, from leadership’s initial assurances of enthusiasm prior to the NBC’s start date to leadership’s active facilitation of professional connections between the NBC and the ED operations team to support materials construction and necessary EHR modifications, the ED Pharmacy team to ensure quick access to desired medications and intralipid in case of complications, and other relevant consulting services. In addition to these connections, the NBC is afforded time to present program updates at least once annually at the monthly department faculty meetings.

The faculty NBC enlisted the support of consulting services that are frequently involved in the treatment of patients who receive nerve block procedures: anesthesia, orthopedic surgery, and trauma surgery. To enhance coordination across clinical units [PRISM-OPI], the NBC met with the leadership of these groups to develop a shared model of care that included use of nerve blocks. This was aimed to both perform the procedure earlier in a patient’s stay in the ED and reduce the frequency with which consulting physicians recommended against the use of nerve blocks to ED providers (Figure 2). Additionally, the NBC met with ED nursing leadership to both explain the rationale for UGNBs and the importance of associated nursing orders such as cardiac monitoring and post procedural neurovascular checks which are needed to support patient safety.

In line with shared goals and collaboration [PRISM-OC], it was confirmed that a shared goal among all parties was to provide safe and efficacious pain control to patients presenting to the ED with acute or chronic painful conditions. As the program has grown there has been increasing acceptance and adoption from the admitting service and at times the ED team is asked to perform the procedure given a multi-year track record of performing UGNB safely and effectively. One of the primary issues raised by anesthesia colleagues was poor real time documentation on UGNBs being done in the ED. As such we established a goal for better on-patient documentation (Figure 3) as well as a push for real time documentation in ED provider notes.

Shortly after starting the program, the nerve block procedure note was updated in the Epic EHR to both ensure adequate billing for the procedures being performed and to push interdepartmental communication (Figure 4). Knowing that revenue generation would be important to support the UGNB program sustainability, the NBC worked with the hospital billing department and Epic analyst team to ensure that the correct Current Procedural Terminology (CPT^Ⓡ) codes were being generated by the documentation of the nerve block procedures. Another reason for the updated note was the value of research and dissemination of knowledge. The University of Colorado was one of the founding sites of the National Ultrasound-guided neRVE (NURVE) Block Registry, a first of its kind registry of patients receiving UGNB in the ED (16). The new documentation supported information transfer to the registry. The data generated by this procedure note represents payer satisfaction and reimbursement [PRISM-EE] factors and provides performance data [PRISM-ISI] for monitoring progress, made possible by the department’s informatics resources and commitment to data and decision support [PRISM-OC] and aligned with the department’s expectation of sustainability [PRISM-OC].

With these organizational and administrative barriers addressed, the NBC turned his attention to interventions aimed at practicing ED providers in the department—addressing the barriers of frontline staff, enhancing readiness [PRISM-OPI], and leveraging organizational systems and training opportunities [PRISM-OC]. While there were indications that established faculty in the department were reluctant to integrate UGNBs (20), it was postulated that more junior physicians would not be. Starting in July of 2022, a resident physician NBC (25) effort was instituted—representing adopter training and support [PRISM-ISI]. This effort consisted of self-identified resident physicians with a particular interest in nerve blocks and providing them with focused, high yield education so that they were prepared to perform UGNBs in the ED. The first cohort included a total of three residents (one PGY2 and two PGY3 residents). The next group started in July 2023 and had an additional four PGY2 residents. The UGNB program consisted of focused mentorship as well as leading quarterly two-four-hour in-person educational sessions focused on select nerve block procedures. This effort was further supported by both the EM residency program at a local safety net hospital system which has a shared residency program with the UCH ED and the ultrasound fellowship at the same neighboring hospital with quarterly ultrasound sessions in the residency conference—further evidence of shared goals and cooperation and leadership support [PRISM-OC].

The faculty NBC met with the resident NBCs quarterly for the first 3 years and would do either individual teaching or answer quality assurance questions. The resident NBCs and Ultrasound Fellows at the neighboring safety net hospital hosted a quarterly evening event for all resident physicians featuring one-two blocks with time to practice scanning—providing an opportunity for facilitation of sharing best practices [PRISM-ISI]. Finally, there have been four 90-min ultrasound focused sessions in the resident didactic curriculum annually. Resident and faculty NBCs are also available as an on-shift training resource.

From a systems perspective, one of the first steps taken was to ensure safety for patients—a key barrier for frontline staff [PRISM-OPI] consideration. Addressing this concern involved internal meetings with both our materials group in the creation of our novel UGNB cart and with ED Pharmacy for medications. A mobile supply cart with all necessary nerve block supplies was created to address concerns about clinical efficiency (Figure 5; Table 2). The cart was stationed in a reliable location in the ED and regularly stocked by the NBCs so that materials were easily accessible. The cart also served to address provider discomfort as it included a QR code to a free iPhone App (26) that serves as a just-in-time resource for reviewing nerve blocks. Additionally, there was a QR code linking to a free iPhone App that facilitates calculating maximum allowable doses of local anesthetic medications to avoid Local Anesthetic Systemic Toxicity (LAST) (27), and pre-printed nerve block aftercare instructions for patients.

The cart started with an echogenic tipped needle that was not well visualized under ultrasound, so we quickly pivoted to the B Braun Stimuplex Needle due to its enhanced visualization under ultrasound—demonstrating attention to usability and adaptability [PRISM-OPI]. The cart also had preprinted discharge paperwork for patients getting a block then being discharged to facilitate both standardized return precautions and expedite dispositions. For our pharmacy colleagues, we met to ensure that we had intralipid in every Pyxis medication dispenser in the ED in the case of LAST (with no cases of LAST observed in the past 3 years). The cart was built to be entirely comprehensive in that it had all necessary elements for any potential UGNB apart from medications. With time, one of the biggest limitations encountered was the re-stocking of the cart. To better support sustainability [PRISM-OC], the department decommissioned the cart and pivoted to a single use ED Nerve Block Tray in April of 2025 that has been extremely well received and requires minimal manual labor.

In September of 2023, two additional faculty members were hired and helped support expansion of the UGNB program. Both were fellowship trained in point of care ultrasound (POCUS) and had expertise in nerve blocks (RT, MH). These hires expanded the dedicated team [PRISM-ISI] available to support the program.

In the fall of 2023, 9 new ultrasound machines were deployed in the department. These new machines provided improved hardware and imaging quality and introduced new needle profiling technology. This technology affords providers better ability to visualize their needles during UGNB, improving safety of the procedure (28). It is notable that these were purchased because the previous machines were greater than 5 years old and due for updating, not specifically to facilitate UGNBs. Organizational leadership support [PRISM-OC] for improved equipment and amenability to adaptable protocols and procedures [PRISM-ISI] enhanced ability to observe results [PRISM-OPI] among UGNB providers.

The following spring, the NBC successfully advocated for the addition of nerve block procedures to four key ED treatment protocols (image–clinical pathways). The department is heavily protocol driven, with EHR-embedded, interactive guidelines called “Pathways” existing for commonly encountered scenarios in the ED—an important aspect of organizational culture and systems [PRISM-OC]. These pathways are multispecialty, interdepartmental agreements that are consensus driven for evidence-based best practices. Providers in the department are expected to follow these pathways in most cases to provide standardized care to patients. Providers are encouraged to refer to pathways while on shift. However, data surrounding pathway utilization is inherently limited because it requires a provider to access the pathway in order to be tracked and more experienced providers may not use them with every encounter. Patients receiving care via the Geriatric Hip Fracture, Rib Fracture, Pelvic Fracture, or Atraumatic Low Back Pain pathways were identified as most likely to benefit from UGNB (Figures 6–9). Within these pathways, a recommendation to consider an UGNB was added, as well as links to helpful resources such as review of sonoanatomy and procedural details of the relevant UGNB. These changes encouraged providers to perform UGNBs by providing organizational support for the decision as well as reassurance that nerve blocks are safe and effective.

To further bolster the safety of nerve block procedures in the department, a nerve block order panel was instituted the following summer. This panel was created in Epic (29) with the help of EHR analysts (Figure 10)—again leveraging department systems and data infrastructure [PRISM-OC]. This included easily navigable orders for local anesthetic medications to increase clinician ordering efficiency and weight-based dosing of local anesthetics to reduce the chance of a dosing error and risk of LAST—representing adaptable protocols [PRISM-ISI] and reducing burden and enhancing usability [PRISM-OPI]. It also included nursing orders for before and after nerve block patient monitoring for patient safety. These orders included placement of cardiac and pulse oximetry monitoring and assessment of pain scores at regular intervals. This would provide feedback to the team about the efficacy of their nerve block in controlling pain as well as creating a protocolized screening process for adverse reactions—a demonstration of the UGNB program’s focus on relationship and communication with adopters [PRISM-ISI]. The order panel also included an “as needed” order for intralipid so that it could be accessed quickly in case a patient experienced an adverse reaction to local anesthetic medication. As a part of the new order panel, ED pharmacists would prepare the anesthetic medication(s) in a syringe and hand-deliver it to the ordering provider further supporting safe medication dosing and provider efficiency.

In the Spring of 2024, nerve block program faculty were made aware by providers that the nerve block cart was not being reliably stocked with necessary materials. Instead of being able to use the cart, clinicians were going to the supply room to find specific materials (such as nerve block needles) in order to perform block procedures. This threatened the efficiency—and thus sustainability [PRISM-ISI] of performing the UGNB procedure and potentially undoing the progress that had been made with the initial implementation of the nerve block cart. To address this problem, the NBC worked with a private industry partner BBraun (30) to stock a prefabricated kit specifically tailored to ED nerve blocks. This kit contained all the supplies needed to perform a nerve block procedure with the exception of local anesthetic medications. That April, the nerve block kits were stocked in the supply room, and the nerve block cart was decommissioned—further evidence of adaptable protocols and procedures [PRISM-ISI].